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Managed care organization
subjectivity and enrollment of workers

If a worker's primary residence is more than 100 miles
outside the MCO's authorized GSA, the worker is not subject to the managed
care contract [ORS
656.245(4)(a)]. A subject worker must be able to access MCO medical
providers within a reasonable distance from the worker's place of employment
[OAR 436-015-0030(4)(f)].
When an enrolled worker lives outside the MCO's authorized GSA, the
worker may treat with a non-MCO provider who practices closer to the
worker's residence as long as that provider agrees to comply with the
MCO's terms and conditions. But, if there is an MCO panel provider (of
the same category as the non-MCO panel provider) located closer to the
worker's residence than the non-MCO provider, the enrolled worker must
treat with the MCO provider [OAR
436-015-0030(4)(g)].

Insurers may enroll workers receiving medical treatment for an accepted claim, regardless of the worker's date of injury or medically stationary status. However, if the worker is not medically stationary at time of enrollment, the insurer must notify the worker of his or her right to request a review by the MCO if the worker believes that changing providers would be medically detrimental [ORS 656.245(4)(a) and OAR 436-010-0275(6)].

Insurers may choose to enroll a worker in an MCO
before claim acceptance. The insurer's enrollment letter to the
worker must explain that the insurer will pay for all reasonable
and necessary medical services received by the worker that are
not otherwise covered by health insurance, even if the insurer
denies the claim, until the worker receives actual notice of the
denial or until three days after the insurer mails the denial
to the worker (whichever happens first). If the worker chooses
to treat with a non-panel primary care physician or authorized
nurse practitioner who agreed to the terms and conditions of the
MCO, payment of medical services is not guaranteed [ORS
656.245(4)(b)(B)].

If a worker chooses to treat within the MCO before enrollment, the insurer or self-insured employer is not obligated to pay for the worker's medical services unless the insurer or self-insured employer later accepts the worker's claim [ORS 656.245(4)(b)(C)].

If a worker's claim is denied, the worker may treat outside the MCO after the date of denial until if or when the denial is reversed. If the claim is finally determined to be compensable, the insurer or self-insured employer must pay for all reasonable and necessary medical services received by the worker from sources outside the MCO [ORS 656.245(4)(b)(D)].

A worker of a noncomplying employer may be subject (after appropriate enrollment notification) to a contract between the assigned claims agent and an MCO [ORS 656.245(4)(a)].

If an MCO contract expires or terminates without renewal, a worker is no longer subject to that contract. When this occurs, insurers must provide written notification to workers informing them they are no longer subject to the contract [ORS 656.245(4)(a) and OAR 436-010-0275(13)]. A worker may become subject to a subsequent managed care contract. Should this happen, the worker may choose to continue treating with his or her attending physician or authorized nurse practitioner under the expired or terminated contract, as long as that attending physician or authorized nurse practitioner agree to comply with the rules, terms, and conditions of the subsequent MCO [ORS 656.245(4)(a)].